Penny Wise: Cutting HIV Prevention and Treatment Programs

Today’s Managing Health Care Costs Indicator is $11,388

That’s how much it costs per patient in the AIDS Drug Assistance Program (ADAP) program  -- which purchases HIV medications for those without health insurance.  Much of this is funded through the federal government – although ADAPs are administered through each state.

The Washington Post and NPR reported this spring about growing waiting lists for ADAP –over 8000 people in May.  South Carolina’s preliminary 2011 budget would have eliminated its HIV prevention and treatment programs altogether.  Some states like Virginia were bumping patients off the ADAP program if their T cell count rose.  Florida  has the largest HIV drug waiting list, and is considering decreasing the income threshold for eligibility to under $22,000 per year.

That might seem fair, to restrict access to those who are  poorest or sickest, but it’s a terrible clinical idea.  Intermittent use of anti-HIV medications is more likely to lead to drug resistance. Also, those on effective anti-HIV medication are substantially less likely to transmit the disease. 

The Boston Globe  reported yesterday that a federal cut of $4.3 million, about a quarter of the anti-HIV budget, will lead to discontinuation of condom distribution programs, outreach to gay men, and community case workers who work directly with HIV patients.   The federal government is shifting its investment from prevention and from states with low transmission rates to testing and treatment and states with higher transmission rates.

Cutbacks in HIV prevention are likely to be costly in the future – public health interventions are far more cost-effective than treating preventable cases later.  Cutting back on drug treatment is a special tragedy.    Highly Active Anti-HIV therapy (HAART) is one of the medical miracles witnessed by my generation of physicians.  Patients with HIV once uniformly died 18-36 months from initial diagnosis. They went blind from cytomegalovirus, they were pockmarked with Kaposi’s Sarcoma, and they were breathless from pneumocystis pneumonia.  They spent weeks or months in the hospital, suffering from wasting and from central nervous system lymphomas.  

All that now seems like the Dark Ages.  The dread disease that was a rapid death sentence in 1994 is now a chronic disease – a bad one – but one that is treatable and where patients can live normal lives (and remain working and paying taxes) for decades.  

We should not restrict access to life-saving HIV drugs.